Scottish Cosmetic Interventions Expert Group Report July 2015

2. Background

Cosmetic procedures: An overview of the market

There is currently a lack of internationally agreed terminology to describe what cosmetic procedures are and how they should be defined. The UK Cosmetic Surgery Interspecialty Committee (CSIC) previously defined cosmetic surgery as an area of practice involving:

"Operations and other procedures that revise or change the appearance, colour, texture, structure, or position of bodily features, which most would consider otherwise to be within the broad range of 'normal' for that person".

Cosmetic surgery does not constitute a defined medical specialism, in contrast to for example, plastic surgery, maxilo-facial surgery and dermatology. As a result, some procedures may be performed by a range of specialist doctors (e.g. rhinoplasty^[2]) and some could be performed by those with no specific mandatory specialist training.

Cosmetic procedures refer not only to surgery but also include a large variety of non-surgical procedures, such as injection of botulinum toxin (several different brands and an example is 'botox®') or dermal fillers. A commonly used distinction between invasive and non-invasive procedures is whether a surgical incision is required to carry out the procedure. Unfortunately, terminology remains highly variable and the proliferation of new treatments adds to the challenges in understanding the range of available procedures. In this report, the terms 'cosmetic procedures' and 'cosmetic interventions' will be used interchangeably to refer to both non-surgical and surgical procedures.

In addition to the diversity of procedures available, many different types of providers may offer services. For many non-surgical procedures no mandatory qualifications, skills or training are stipulated. There is anecdotal evidence that a huge variety of providers exists, often describing themselves using a range of terms. The diverse descriptions of providers makes assessments of their competence difficult for both the general public and even trained health care professionals & practitioners (see Box 1). In this report, the terms health care professional and cosmetic practitioner will be used to distinguish between two groups:

• Health care professional- providers of procedures subject to their code of practice who have received a formal health qualification and are subject to compulsory licensing with a regulatory professional body in order to practice within the UK. This includes doctors, dentists, dental care professionals, clinical scientists, nurses, pharmacists, physiotherapists, occupational therapists and others. The scope of practice for doctors, dentists, dental care professionals and nurses can include cosmetic procedures.
• Cosmetic practitioner- providers of cosmetic procedures who are not subject to a formal system of compulsory professional regulation. This includes beauty therapists, hairdressers and a range of other providers.

Box 1: Examples of providers of non-surgical cosmetic procedures

Over the last decade, the uptake of cosmetic procedures appears to have soared. According to market research data, cosmetic procedures were worth £2.3 billion in 2010 and up to £3.6 billion in 2015 (Keogh Review^[3]). The market rate of growth in the sector shows no signs of slowing. According to the British Association of Aesthetic Plastic Surgeons (BAAPS), the number of cosmetic surgical operations increased by an average of 17% between 2012 and 2013, with some procedures increasing far more quickly - for example, liposuction increased by 41%. The volume decreased in 2014 due to a reduction in the number of breast implant operations which had peaked during the PiP implant actions in 2012/13; other cosmetic procedures continue rising.

While robust data are lacking, there are indications that the increase in non-surgical cosmetic procedures may be even greater. For example, Google searches in the UK for terms related to non-surgical procedures appear to have increased more rapidly than for surgical cosmetic procedures (see Figure 1).

Figure 1: Trends in searches for four terms related to the use of cosmetic procedures on the Google search engine

Source: Google trends. Purple = tooth whitening. Blue = botox®. Red = boob job. Green = skin clinic. Note: An improvement to Google's geographical assignment was applied on 1/1/2011.

As cosmetic procedures have grown in popularity, the diversity of settings in which they are performed has increased. Historically, cosmetic surgery was almost exclusively performed within hospital settings. In contrast, the range of procedures currently available can be performed within many locations - including private clinics, dental surgeries, beauty parlours and client homes.

While there is a lack of robust data on the consumers of cosmetic procedures, the available evidence suggests that females have been the predominant consumers to date. However, the growing popularity of procedures more targeted at males (such as hair transplantation) may herald an increase in uptake amongst this population.

Advertising and changing in social norms

Paralleling the growth in cosmetic procedures has been an emerging concern amongst health professionals and academics that aggressive marketing may be bringing about adverse changes in social norms. Breaches of the ASA voluntary code appear to be commonplace. In relation to the marketing of cosmetic procedures, the Committee of Advertising Practice (CAP) specifically cautions against the use of time-limited offers and that adverts should not encourage consumers to undergo unnecessary or unwanted procedures. It is relatively easy to find examples where current advertising standards are breached (for example mention of 'botox®' on front page of websites).

The Keogh 2013 Report^[4] raised concerns that the growing normalisation of cosmetic procedures, coupled with its aggressive marketing, may be fuelling concerns with body image. The Girls Guides' Association has been monitoring satisfaction with body image over the last five years. Amongst adolescents, there appears to be a growing dissatisfaction, as shown below.

Figure 2: Percentage of girls who are happy with the way they look by age group, for the period 2009-2013

Source: The Girl Guides' Association, Girls Attitudes 2009-2012^[5]

As a consequence of the Department of Health's endorsement of most of the recommendations of the 2013 Keogh Review, the CSIC of the Royal College of Surgeons was established. Its work has been conducted in parallel to the SCIEG, with a remit that includes the development of minimum standards for the training and practice of cosmetic procedures (often referred to as 'credentialing').

The Department of Health also gave a mandate to Health Education England (HEE) to work with regulators, royal colleges and other stakeholders to conduct a review of the qualifications required for non-surgical cosmetic interventions, the qualifications required to be responsible prescribers and to make recommendations on accreditation of qualifications and course delivery. The non-surgical cosmetic interventions within the framework are:

• Botulinum toxin
• Dermal fillers
• Chemical peels
• Skin micro-needling
• Mesotherapy
• Laser treatments
• Intense pulsed light therapy
• Light emitting diode treatments
• Hair restoration surgery

The final document on training and competences will be available in the spring of 2015. At that stage, there will be a need to assess the work with stakeholders on the relevance for Scotland.

Given the overlapping regulatory framework, with some matters organised at a UK-level and others at a Scotland-level, the SCIEG has liaised with relevant stakeholders across the four nations.